NHS urgent care review proposals 'not deliverable' says Buckman

Exclusive Many of NHS England’s proposals for the future shape of urgent care are ‘not deliverable’ and lack detail, says GPC chair Dr Laurence Buckman in a robust response to plans that included GPs providing 24/7 ‘decision support’ for their patients.

Dr Buckman, giving the first indication of GPC’s response to the proposals published by Sir Bruce Keogh this week, railed against the suggestion that GPs should be available to provide ‘decision support’ out-of-hours and said many of the proposals in the report would only be deliverable by reinstating funding to GP cooperatives.

He said there was ‘very little’ he would disagree with the analysis in the report that the problems in emergency care were multifactorial, but said that the proposals - such as seven-day same-day access to a primary care team integrated with the practice - were completely unrealistic.

The report - published by NHS England this week - begins a consultation on a list of possible options to solve the crisis in the urgent care system.

Many of the proposals related to greater access to GPs out-of-hours - but not necessarily the patient’s practice - with more out-of-hours telephone consultations and giving GPs same-day access to specialist opinions.

But the most controversial proposal was for practices to provide 24/7 ‘decision support’. Dr Buckman said: ‘I can’t see how that is deliverable. I think the idea of having a doctor on the front line or very near it, in any kind of urgent care situation, is essential.

‘I think if it is a primary care thing then it should be a primary care physician and I think there are people who will do that, for money. For a suitable payment they’ll do it.’

He added that providing same-day access to a GP was something that should only be available for urgent and emergency care. He said: ‘If what they mean is on a Sunday, then I am sorry, you can’t deliver that kind of service unless for urgent and emergency matters. But I am not providing a routine service for things that are not so important.

‘I think the GP co-ops would have been admirably suited to the task if they hadn’t been defunded to pay for 111. That was what we said all along, that GP out-of-hours service provide, largely, a very good level of service, and if you take their money away they won’t be able to provide a good service and that is what’s happened.’

But Dr Buckman also said the analysis of the problems in the report was fair. He added: ‘There is very little in the Keogh report we would disagree with. I would share his analysis. Sometimes language is a bit loose, where I would say “Well where’s your evidence for that”, but even then I still agree with it.

‘His conclusions are: it’s confusing, there are too many entry points, a lot of money has been wasted, a lot of things have been set up that do nothing for patients, and he is right. All of that is right.

‘The level of out-of-hours service is variable, we know that, and that is because different out-of-hours providers provide different things and that is partly because different PCTs have funded different levels of service.’

The leader of the biggest LMC in the country, Dr Michelle Drage, chief executive of Londonwide LMCs, said she ‘would take issue’ with the BMA for welcoming the report, hinting at a possible row down the line between grassroots GPs and the trade union.

She said: ‘If you actually invest properly in in-hours GP services and support practices in taking on more doctors, more practice nurses and have a decent support service around them in the form of an extended primary care team, then you don’t need to go through these reviews and consultations which are a huge expense just to process to invent something that we know we could do if the service was properly run.

‘I find it highly unlikely that NHS England’s proposals will be welcomed by general practices, although I know that the chair of the BMA has welcomed the review and I would take issue with him for doing that because I think that yet again it leaves general practice out on a limb.’

What's the point? Unlike our Welsh and Irish counterparts, Buckman & Co. Gave up on the last contract months before the imposition and sent a letter of surrender to all of us detailing his frustration but no action.

We'll just have this imposed again, unless the grassroots start taking matters to their own hands

Too little far too late does come to mind to describe the BMA. They may try to say the right things but sadly no-one is listening, certainly the Government pays them no attention at all. The Government has no interest in what is deliverable. There is no point the BMA talking to the Government as the decisions are already made. The BMA has to adopt a position in direct conflict to the Government for them to even listen, the BMA will not do this and there is no grassroots leadership to take over for the inaction of the BMA.

All GPs cease membership of the BMA. They use your money to talk but not act. If they had no money they would have to change their stance and listen to the grass root GPs opinions. Do it! Don't think about! Stop moaning and do something to get our so called representatives to act on our behalf and not politicking with the DOH!

The only way to take back control of our profession is to leave the so called security of GMS and bring in real pricing of the service in the same way the dentists did. You don't see them pushed around, do you?

Having skimmed through the review, I actually agree with Laurence that it is to be welcomed as it puts paid to the myth that A+E is overwhelmed because we GPs are never there. How about this for a radical idea - do away with the QOF, which is has lost its credibility as evidence based preventive medicine and just become a gaming exercise for us to screw a few meagre quid out of the system for hoop jumping with interventions that just over-medicalise the worried well, and pay us properly from the proceeds for providing a proper minor illness service? Leave the prevention stuff to the call-handlers working to protocols, which, along with a phlebotomy clinic to do the bloods etc, is all it needs anyway (and little harm to be done if they get it a bit wrong) so the punters can access that 24/7 without needing time off work?

Come on BMA, stop interfering in public health stuff like alcohol pricing and scrutinising smokers, and give the government a suggestion like this to chew on...

Please kindly stop bemoaning the BMA and negotiators, who have done the best they could in the face of a government unwilling to tolerate GP's getting paid more money with the 2004 contract and have spent years trying to claw it back.

The problem is within General Practice, probably not the people reading this, but the silent majority who showed the DOH that the gun the BMA held to try and stop the contract changes, in fact all the NHS changes etc, was in fact not even loaded, when the planned walk out, was completely unsupported, and had no impact.

The 4 day Jubilee walk out (sorry holiday) was more of a disruption to services, but since then it gave the DOH bullies a green light to continue to bash GPs - in the media and steal our pocket money (pay/pensions/extra taxes/pay for locums) - fully safe in the knowledge, there were no consequences, as the profession couldn't organise a pi55 up in brewery.

funding has to flow in primary care and that is the bottom linein our woods we have a GP cooperative [excellent service] and an AQP provider aboutwhich no body knows what they do and the stupid rule that one cannot opt from the other

There are 3 "needs" in "out-of-hours":1) the REAL need: those patients who need to receive urgent care in order to avoid adverse outcomes. Most of these are, in fact, emergencies and should be assessed and treated in hospital. Simply put, most of these patients are not GP "out-of-hours" patients.2) The PERCEIVED need: these are those who want the service to be there in case they need it. Most of the time they don't - and hence the service is a bit of a White Elephant as far as they are concerned. Mixed into this number is a significant component (probably the majority) of "convenience beghaviour": more convenient to attend out-of-hours than get an in-hours assessment3) the need to be needed: this is the provider's need to "make a difference". Do they really make a difference? Not as much as they would like to imagine.

The key to out-of-hours care is adequate access duriong "normal" hours - and reduced convenience behaviour. Government will NOT address "convenience behaviour" as this implies restrictions, however realistic, on "personal freedoms' and hence loss of votes. And so we end up with an expensive, unsustainable solution with endless finger-pointing, inadequate funding and irrational thinking.

The State has infantilised the population, "I need help with every thing because its a health matter" splinter out of finger and so forth.Unfortunately some of the professions conspire with the populous by inducing Healthcare Dependence. It may be an enormous ego trip to believe 2,000 people cannot break wind without your permission, but it is not a effecive model of personal enpowerment.Comissioning is missing the issue, I see numerous proposals to replace the dependency with lest costly staff, " personal lay health advisor" job description springs to mind- basically a state remunerated Grandparent-rather than tackle the issue that there are occasions in every area of life when to paraphrase Kennedy "its not what the state does for me but what I can do for the state". Self management of self limiting minor health issues should be first on the list.

Doctors are supermen - they can work 24 hours/day, 365 days a year - remember the red book.Until and unless we doctors define health and safety in hours worked, we will always be expected to do more.It took the EWTD to define junior hours. If it was left to the BMA, they would still be doing 120 + hours a week.This is the one thing the BMA as an Union should be doing. Sure, alcohol pricing and smoking are important for public health, but what about your member's health - half of whom are depressed and burnt out and many leaving the profession because they cannot cope with workloads. Come on BMA, any suggestions/ guidelines on health and safety for doctors ?